How To Address Failed Peroneal Tendon Surgery

Continuing Education Course #155
August 2007

I am pleased to introduce the latest article, “How To Address Failed Peroneal Tendon Surgery,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

As Neal M. Blitz, DPM, FACFAS, points out at the beginning of his article, the long-term effects of peroneal loss may lead to structural foot deformity yet there is little literature on the subject of revisional peroneal tendon surgery.

In addition to discussing key preoperative measures, Dr. Blitz offers step-by-step pearls on peroneal tendon repair treatment options such as the peroneal stop procedure and the use of tendon grafts.

At the end of this article, you will find a nine-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This continuing education course will also be available on Podiatry Today’s Web site (www.podiatrytoday.com) so you can submit your responses online. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 109 and successfully answering the questions on pg. 114. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Blitz has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists
RELEASE DATE: August 2007
EXPIRATION DATE: August 31, 2008
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• review key preoperative questions one should consider prior to revisional surgery;
• discuss what to look for in the clinical exam, radiographs and diagnostic injection when evaluating patients who have failed peroneal tendon surgery;
• review key pearls for performing a peroneal stop procedure;
• cite the pros and cons of autografts and allografts when using tendon grafts; and
• discuss how the presence of cavovarus affects treatment options.

Sponsored by the North American Center for Continuing Medical Education.

Foot and ankle surgeons often identify and treat peroneal tendon injuries. These injuries may involve attrition, longitudinal splits (partial or full thickness) and/or complete rupture (although this is much less common). Both tendons may be involved but peroneus brevis injuries appear to be more prevalent.

When surgery is necessary to repair the injured tendon(s), primary repair of the damaged portion of the tendon is usually the procedure of choice. Fortunately, with primary repair, the outcomes are functionally good and post-op failure is uncommon.
In my opinion, when peroneal tendon surgery fails, it may be as bad or worse than a neglected or failed Achilles tendon rupture because the long-term effects of peroneal loss may result in a structural foot deformity, specifically cavovarus. As such, the surgeon should make attempts to prevent a resultant cavovarus by restoring the functional of the peroneals, specifically peroneal brevis.

The peroneal tendons are lateral compartment, lower leg muscles that are responsible for plantarflexion and eversion of the ankle. The peroneal brevis is the main and strongest everter of the foot, and a direct antagonist to the medial inverters. The peroneal brevis prevents posterior tibialis overpull and cavovarus. The peroneus longus has significant effects on the first ray during gait. Both tendons are important in stabilizing the ankle against inversion. Loss of function of one or both of these muscles may result in secondary problems such as ankle instability, first ray elevatus and potential cavovarus.

There is little literature regarding the management of failed peroneal tendon surgery. While there is no specific treatment algorithm that will specifically guide the surgeon, I have included a table that matches the specific tendon injury with respective treatment options (see “A Guide To Treatment For Peroneal Tendon Defects” below).

Of course, distinguishing between a failed surgery involving the peroneal longus and a failed surgery involving the peroneal brevis is critical because one would treat these somewhat differently. In some situations, both tendons may require revision. When considering revisions for failed peroneal tendon surgery, the surgeon may need to consider concomitant procedures as well.

What You Should Consider Preoperatively
Prior to revisional peroneal tendon surgery, there are many preoperative questions that one must address. Why did the primary surgery fail? Was there an underlying deformity that predisposed the initial surgery to failure? What surgery was done previously? What are the patient’s current symptoms and complaints? Be sure to obtain the previous operative and clinical notes. Also review any imaging studies such as magnetic resonance imaging (MRI) relating to the index surgery.

One must consider the patient’s complaints closely. Are the complaints localized to the peroneals and consistent with the failed operation? Is the patient having secondary symptoms such as ankle instability that warrant further investigation? A thorough clinical evaluation should involve manual muscle testing and evaluation of the foot architecture as well as the first ray and heel position. Underlying structural or biomechanical deformity may have caused the initial surgery to fail and one may need to address this with a concomitant procedure as part of the revision tendon surgery.

Proceed to obtain the following radiographs:
• a calcaneal axial view to rule out intrinsic heel varus and the presence of a hypertrophic peroneal tubercle;
• a bilateral ankle stress view in the presence of ankle instability in order to identify incompetent lateral ankle ligaments; and
• weightbearing foot films.
Performing a diagnostic injection of lidocaine into the peroneal sheath is critical when considering revision peroneal surgery. Patients who do not demonstrate significant relief are probably poor candidates for revision unless the preoperative complaints are more functional in nature. Consider using radioopaque dye to verify placement.

Unappreciated ankle instability or a hypertrophic peroneal tendon may have resulted in the failure of the first surgery. Of course, a hypertrophic peroneal tubercle may cause attrition and tears to the peroneals. Regarding ankle instability, it may be unclear if the ankle instability was present before or after the index operation or the result of an ineffective/weak/absent peroneal tendon.

A preoperative MRI is required to evaluate the peroneal tendons and to further distinguish between peroneus longus pathology and/or peroneus brevis pathology. In some situations, the clinical exam and imaging studies should specifically identify which peroneal tendon is involved. However, one may not truly appreciate the extent of the tendon damage until the time of surgery.

Weighing The Peroneal Tendon Repair Options
Very often, surgeons will find that the tendon is severely damaged from the index operation. It may be fibrosed, scarred, hypertophic, tendinosed, longitudinally torn and filled with non-absorbable suture. The tendon will likely be non-reconstructable. Accordingly, the repair then involves managing a tendon defect. Options for repair depend on which tendons are deemed non-reconstructable.

Reestablishment of the peroneus brevis is more critical than reestablishment of the peroneus longus. This is not to say that peroneus longus loss is insignificant but its loss is not as devastating as the loss of the peroneus brevis. Again, because the peroneal brevis is the main everter of the foot and a direct antagonist to the medial inverters, the surgeon must restore it to prevent posterior tibialis overpull and cavovarus. When both tendons are involved, the repair focuses on restoring the peroneal brevis.

The repair options for the peroneal tendons include the peroneal stop, a local tendon transfer or a tendon graft (autograft/allograft).
One may use a tendon graft in any circumstance when repairing a tendon defect and surgeons should always consider it. However, for isolated peroneus longus and brevis defects, one may consider other alternatives.

Key Insights About The Peroneal Stop Procedure
Surgeons may treat an isolated peroneal longus or peroneal brevis defect with a peroneal stop, which is a tendon transfer. The procedure involves resecting the diseased portion of the tendon and subsequently performing tenodesis of the proximal tendons together behind the ankle, and tenodesis of the distal ends on the tendons.

In order to perform a peroneal stop, one of the peroneal tendons needs to be intact in order to accept the transfer. With an isolated peroneus longus defect, one would suture the stump of the peroneus longus to the brevis at the cuboid notch. This maintains the peroneus longus muscle, which will still have action on the first ray (through the peroneal brevis) during stance. With an isolated peroneus brevis defect, suture the stump of peroneus brevis (that is attached to the fifth metatarsal base) to the intact peroneus longus.

If more tendon length is needed to repair the defect, transect the peroneus longus as far distally under the cuboid notch. Then anchor the peroneus longus into the fifth metatarsal base. While this should not result in any clinical significance, it may theoretically result in a dorsal bunion (first ray elevatus), although specific studies with the peroneal stop procedure have yet to be performed. Of course, patients with existing first ray issues may not be ideal candidates for this procedure and one may need to consider other methods to restore peroneus brevis function.

Surgeons may entertain other tendon transfers, especially when both tendons are non-reconstructable. The flexor hallucis longus tendon is probably the most reasonable tendon transfer for this indication because of its lateral proximal posterior location and the ability to obtain several tendon lengths.

Again, the focus is restoration of peroneus brevis function. One would transfer the flexor hallucis longus into the stump of the peroneus brevis or into the base of the fifth metatarsal. However, flexor tendon transfers can be involved. While the surgeon should consider them, they may not be a first-line option.

What About Tendon Grafts?
Tendon grafting is an excellent option when both peroneal tendons require reconstruction.

One may use autograft or allograft, and should consider this on a case-by-case basis. Autograft excludes the risk for viral transmission from the graft but involves a secondary surgery site (donor site) that may cause morbidity in a distant location. Harvest options for autograft include the hamstring, plantaris or a contralateral split peroneal longus free tendon graft. Surgeons may consider other split tendon grafts in the foot and ankle may as well. In general, semitendinosis and gracilis autografts are probably the most favored tendon autografts. Orthopedic surgeons have used these autografts in anterior cruciate ligament reconstruction because of its ease of harvest, long length, strength and little donor site morbidity.

A recent case reported by Ozer, et al., in 2005 demonstrated the use of a hamstring autograft for non-reconstructable peroneals. I have used a hamstring autograft for peroneal tendon reconstruction and the major complaint was related to the donor site due to difficulty to cross the affected leg over the other to put on socks. The peroneal repair site healed without any functional limitations.

Additionally, the surgeon may consider the plantaris for an autograft but its variable presence and thinness are not promising for peroneal tendon repair. Split free, peroneus longus tendon grafts are useful for ankle stabilizations because of their location, tendon quality and length. However, harvesting tendon from the contralateral side may result in bilateral peroneal problems. The use of contralateral peroneus longus free tendon graft has not been reported for this indication.

Of course, one can avoid donor site morbidity with the use of allograft. However, there is a risk of bacterial infection if the graft is contaminated, not to mention the risk of viral transmission from the donor. One hundred percent sterilization is not possible as the tensile strength and collagen are also affected with certain processes. Though allograft is not as strong as autograft, it is typically sufficient. Allograft repairs are practical. I especially prefer them when multiple grafts are needed and consider their use on a case-by-case basis.

One should remove a hypertrophic peroneal tendon if it is present. Also be sure to correct associated ankle instability. In some cases, a Brostrom procedure may be appropriate although surgeons may need to consider more anatomic repair in other cases. One should avoid any ankle stabilizations that involve harvesting the peroneal tendons in this situation. Consider allograft anatomic reconstructions, especially if you are using allograft for the peroneal tendon repair. Be sure to order enough graft for all the repairs.

What You Should Know About Cavovarus
In the presence of cavovarus, one should consider rearfoot fusions because a tendon repair will likely not reverse the structural foot problem, especially with semi-rigid or rigid conditions. In some cases, surgeons may combine isolated fusions with peroneal tendon repairs.

Keep in mind that you may perform subtalar and calcaneocuboid joint fusions through the same incision as a peroneal tendon repair. In theory, a triple arthrodesis takes the place of a peroneal tendon repair unless you want the peroneal tendon repair to help maintain/augment ankle stability.

If the talonavicular joint is reducible, then one may perform the peroneal tendon repair along with a subtalar and/or calcaneocuboid joint repair instead of a triple arthrodesis. You should consider the first ray position and perform a Coleman block test to determine the need for a dorsiflexory base wedge osteotomy of the first metatarsal or a Lapidus.

Final Thoughts
In summary, management of failed peroneal tendon surgery is not a simple task. It often involves repairing a tendon defect as well as treating any underlying deformity that predisposed the index surgery to failure. One should tailor treatment on a case-by-case basis. Fortunately, failed peroneal surgery is uncommon.

For related articles, see “Persistent Pain After Ankle Sprain: Is A Peroneal Tendon Injury The Cause?” in the September 2006 issue of Podiatry Today, “How To Diagnose Lateral Ankle Injuries” in the October 2005 issue and “A Guide To Understanding And Treating Lateral Column Pain” in the March 2005 issue.

Also check out the archives at www.podiatrytoday.com.

References 

1. Ozer H, Oznur A. Peroneal tendon repair with autologous hamstring tendons. J Foot Ankle Surg. 2005 Nov-Dec;44(6):487-9.
2. Dahm DL, Kitaoka HB. Peroneal Tendon Repair and Reconstruction. In Master Techniques in Orthopedic Surgery. The Foot And Ankle 2nd Ed, pp 293-310, edited by HB Kitaoka, Lippincott Williams & Wilkins, Philadelphia, 2002.
3. Hansen ST. Tendon Transfers and Muscle-Balancing Techniques. In Functional Reconstruction of the Foot and Ankle, pp 439-441, 462-467, Lippincott Williams & Wilkins, Philadelphia, 2000.
4. Blitz NM, Nemes KK. Bilateral Peroneus Longus Rupture Through Bipartite Os Peroneum. A Case Report. J Foot Ankle Surg – In Press.

CE Exam #155

Choose the single best answer to the following questions.

1. The peroneal brevis …

a) has a marginal effect on the first ray during gait
b) facilitates posterior tibialis overpull
c) is the main and strongest everter of the foot
d) none of the above

2. Which of the following may cause a failed peroneal tendon surgery?

a) Underlying biomechamical deformity
b) A hypertrophic peroneal tendon
c) Unappreciated ankle instability
d) All of the above

3. Which of the following radiographs should surgeons obtain prior to performing revisional peroneal tendon surgery?

a) A bilateral ankle stress review even in the presence of ankle
stability
b) Bilateral nonweightbearing AP views of the ankle
c) A calcaneal axial view to rule out intrinsic heel varus and the presence of a hypertrophic peroneal tubercle
d) All of the above

4. When assessing a failed peroneal tendon surgery …

a) surgeons will occasionally find that the tendon is severely damaged from the index operation
b) the surgeon will usually find that the tendon is reconstructable
c) one may discover the tendon is fibrosed, scarred, hypertrophic, tendinosed, longitudinally torn and filled with non-absorbable suture
d) none of the above

5. In regard to using the peroneal stop procedure …

a) for an isolated peroneus longus defect, suturing the stump of the peroneus longus to the brevis at the cuboid notch eliminates the action of the peroneus longus muscle on the first ray
b) surgeons can use the tendon transfer procedure to treat an isolated peroneal longus or a peroneal brevis defect
c) all of the peroneal tendons need to be intact in order to accept the transfer
d) none of the above

6. In regard to tendon grafting for peroneal tendon defects, harvest options for autograft include …

a) the hamstring
b) plantaris
c) contralateral split peroneal longus free tendon graft
d) all of the above

7. In regard to tendon grafting for peroneal tendon defects, which autograft options are the most favored by surgeons?

a) Plantaris and hamstring
b) Semitendinosis and plantaris
c) Semitendinosis and gracilis
d) None of the above

8. __________ are useful for ankle stabilization because of their location, tendon quality and strength.

a) Gracilis autografts
b) Split free, peroneus longus tendon grafts
c) Plantaris autografts
d) None of the above

9. When it comes to the presence of cavovarus, surgeons …

a) should avoid rearfoot fusions
b) should avoid performing isolated fusions with peroneal tendon repairs
c) can perform subtalar and calcaneocuboid joint fusions through the same incision as a peroneal tendon repair
d) All of the above